Recap of the New CAP Guidelines

Pediatrics Update
Brief Summaries for Clinical Practice

After children return to school, respiratory symptoms increase¹ along with visits to the pediatrician’s office. The clinician must be able to distinguish upper from lower respiratory tract disease and initiate appropriate treatment. Lower respiratory tract infection is suspected when a child has the following symptoms: fever, cough, increased respiration rate, abnormal lung sounds, retractions, and hypoxia—indicated by an oxygen saturation of less than 90% to 93%.

The recently published clinical practice guidelines on the management of community-acquired pneumonia (CAP) include evidence-based strategies for use in children older than 3 months.² The expert panel’s 92 recommendations are divided into 7 main topics:

•Site-of-care management decisions.

•Diagnostic testing.

•Anti-infective treatment.

•Adjunctive surgical and non-anti-infective therapy.

•Management of CAP in the child who is unresponsive treatment.

•Discharge criteria.

•Prevention.

The topics are subdivided into 20 specific questions that address when hospitalization or intensive care is indicated, which diagnostic tests are recommended for the clinic or hospitalized patient, what treatments are recommended for uncomplicated and complicated cases, and what prevention strategies are available to the clinician. Ratings for each recommendation based on strength and quality of available evidence can be reviewed in the published guidelines.² This brief update summarizes the highlights of the guidelines to aid the practicing clinician in managing this potentially life-threatening pediatric infection. 

SITE-OF-CARE MANAGEMENT DECISIONS

(Recommendations 1 to 11)

The patient’s history and physical examination findings will provide the information to make the diagnosis of CAP and determine the extent of the evaluation.² In general, no tests are recommended to make the diagnosis in the otherwise healthy, fully immunized child who appears nontoxic and whose clinical presentation is consistent with CAP. Clinicians should obtain pulse oximetry in any child with suspected hypoxemia. Cases in which there is suspicion for pulmonary, metastatic, and systemic complications require a more aggressive evaluation.

DIAGNOSTIC TESTING

(Recommendations 12 to 40)

To aid the diagnostic process in the sicker or nonimproving child, the clinician should consider obtaining blood cultures and sputum cultures (if possible), a complete blood cell count, levels of acute phase reactants, a chest radiograph (Figure 1),³ and testing for viruses and Mycoplasma pneumoniae. Use of tracheal aspirates and bronchoalveolar lavage (BAL), percutaneous lung aspiration, and open biopsy are reserved for intubated patients and severe cases of CAP.

ANTIMICROBIAL THERAPY

(Recommendations 41 to 56)

Use of antibiotics should be avoided, unless there is concern for bacterial infection.² First-line treatment for uncomplicated bacterial CAP in the outpatient setting is oral amoxicillin. When atypical bacterial causes are possible, macrolides are the preferred treatment and laboratory testing for M pneumoniae is recommended, if testing is available in a timely manner.

Inpatient treatment of bacterial CAP may include intravenous ampicillin or penicillin G, ceftriaxone or cefotaxime, or a combination of a macrolide plus ß-lactam antibiotic; treatment choice is decided on a case-by-case basis. Antistaphylococcal treatment must be added when the patient’s presentation provides evidence for Staphylococcus aureus pneumonia.⁴ Improvement of symptoms in children is expected within 3 days of initiating antimicrobial therapy. No antibiotics are needed for viral pneumonia, which is particularly common in preschoolers.

The expert panel advocates the administration of antiviral medications as soon as influenza is suspected in the moderately to seriously ill child, even if it is diagnosed after the 48-hour mark since the onset of symptoms.²

TREATMENT OF CAP COMPLICATIONS

(Recommendations 57 to 71)

Diagnosis of a parapneumonic fluid collection may require the use of a chest radiograph (Figure 2),³ chest ultrasonography, or chest CT. Gram stain and bacterial culture of the fluid is recommended; however, a biochemical profile (pH, glucose, protein, and lactate dehydrogenase) of the fluid is not recommended. The guidelines describe the fluid drainage options; use of a certain option is determined on a case-by-case basis depending on the severity.²

Interventions may include antibiotic therapy alone for small effusions and chest tube placement, with or without fibrinolytics, or video-assisted thoracoscopic surgery for larger fluid collections.

MANAGEMENT OF UNRESPONSIVE CAP

(Recommendations 72 to 76)

The patient who is unresponsive to treatment may have necrotizing pneumonia or a pulmonary abscess. More extensive and invasive testing (including BAL, percutaneous lung aspirate, and open lung biopsy) may be required to definitively determine the causative pathogen.²

HOSPITAL DISCHARGE

(Recommendations 77 to 87)

Patients should be discharged only after they have shown sufficient improvement for at least 12 hours. This includes those patients who have had chest tubes removed.² Outpatient treatment needs to be individualized and depends on family capabilities. Treatment options may include oral antibiotics and continuation of intravenous antibiotics as well as oxygen therapy.

PREVENTION OF CAP

(Recommendations 88 to 92)

The remaining recommendations emphasize the importance of immunization of the child, adult caregivers, and other contacts.² Children should receive all routinely recommended vaccines appropriate for their age, including the 13-valent pneumococcal conjugate vaccine. Adult care givers and contacts should receive influenza and pertussis vaccines. Eligible infants should also receive prophylaxis against respiratory syncytial virus.